Massachusetts Member Appeals Specialist

Job Summary

Detail-oriented and organized, the Member Appeals Specialist will manage member pharmacy coverage appeals from intake through final determination in a fully remote contract role, ensuring compliance with regulatory requirements and internal quality standards.

Key responsibilities

• Manage assigned member appeals, ensuring compliance with regulatory and internal turnaround requirements
• Review appeal submissions for eligibility, timeliness, completeness, and supporting documentation
• Collaborate with cross-functional teams to facilitate timely case progression and resolution

Required qualifications

• Experience handling member appeals in a healthcare, health plan, managed care, or insurance environment
• Demonstrated ability to manage cases through a structured case management system
• Strong understanding of regulatory timelines and compliance-focused workflows
• Proficient with Microsoft Outlook and healthcare-related systems
• Ability to work effectively in a fully remote team environment